Historically he looked after specific cases on behalf of the King, with special regard to collecting revenues that were in the Possession of felons and the confiscation of deodands, wrecks and treasure trove. Over the centuries his work has changed to his present duties and now the Coroner is wholly concerned into inquiring and holding Inquests into cases of violent and unnatural death and treasure trove.
The Coroner has to hold an Inquest when the body of a person is lying within the district of his jurisdiction, and there is reasonable Cause to suspect that the deceased had died a violent or unnatural death, or had died a sudden death of which the cause is unknown. An Inquest must also be held if a person has died in prison or in circumstances as described by specific Acts.
The Inquest is held in a Coroners Court which is open to the public and the press. The public can be excluded from an Inquest or part of an Inquest if it is in the interest of national security.
This very rarely happens and over a period of 24 Years I have never held an Inquest in camera. The Inquest is a fact-finding exercise. It is not a trial, but an inquisitorial process. There are no parties; there is no defence; there is no prosecution; and no one is charged. The Inquest is not a method of apportioning guilt. Formerly the Coroners Court had the power to commit a person for murder, manslaughter, or infanticide. This power was abolished in 1977.
clear and succinct and state that the proceedings and evidence at an Inquest shall be directed solely to ascertaining the following matters : whothe deceased was, how, when and where, the deceased came by his or her death – the particulars for the time being required by the Registration Acts to be registered concerning the death. Neither the Coroner nor the jury shall express any opinions on any other matters.
The matters to be ascertained in an Inquest are laid down in the Coroners Rules, They are
Mandatory for a jury in certain circumstances - a death in prison , in police custody , on railway property .
be considered but the minority must not exceed 2.
The coroner shall have a jury if he has reason to suspect that the death occurred in circumstances, the continuance or possible recurrence of which is prejudicial to the health and safety of the public. The jury consists of not more than 11members and not less than 7. The Coroner at the completion of his summing up will in the first instance seek a unanimous verdict, if this cannot be reached a majority verdict will be allowed to
WI'INESSES The Coroner, depending on the circumstances of the case, will decide which witnesses he will need to call for the Inquest. The Coroner will call witnesses to give evidence on oath who have knowledge of the facts and who he thinks can assist the Court. As well as professional witnesses he may call expert witnesses to give an opinion. In some cases a medical practitioner, whose evidence in the opinion of the Coroner is not in dispute, will not need to attend and his or her statement may be read in Court. However this can be challenged and the person can be asked to attend. All competent witnesses can be compelled to attend.
EXAMINATION OF WITNESSES
Any person who satisfies the Coroner that he is entitled to examine witnesses in accordance
with Rule 20 Coroners Rules 1984 may do so, for example a parent or spouse or member of the family and any person who is a representative of the deceased.
VERDICTS
The conclusion of the Inquest by the Coroner or the jury is usually referred to as the verdict.
There is no statutory obligation that the conclusion be in any particular form. All that is required is that the conclusion should express in concise and ordinary language how the
deceased came by his death. However there is a list of suggested conclusions (verdicts) which are used and which were suggested to standardise conclusions for statistical purposes. Although they are suggested, it must be stressed they are not compulsory. A list of these suggested verdicts include Accidental Death, He or She killed Himself or Herself (Suicide), Unlawful Killing etc. At the conclusion of the hearing a formal record of the inquest will be given, which gives the cause of death and the time place and circumstances in which the injury was sustained, in addition to the verdict.
No verdict shall be framed in such away as to appear to determine any question of Criminal Liability on the part of a named person, or Civil Liability. Riders to verdicts have been disbanded. However there is a Rule 43 Coroners Rules 1984 which state that a Coroner who believes that action should be taken to prevent the recurrence of fatalities similar to that in respect of which the Inquest is being held, may announce at the Inquest that he is reporting the matter in writing to the person or authority who may have power to take such action and he may report the matter accordingly.
PITFALLS AND ADVICE TO
PRACTITIONERS
All medical practitioners should always consult their own medical defence union for advice and possible representation when they are involved in an Inquest.
It is of great importance that every practitioner should keep clear and detailed notes regarding patients under their care. They should always come wi th their notes and be conversant with all details of their involvement with the deceased before the Inquest.
If the practitioner seeks the advice of a colleague concerning the deceased this advice should be recorded in the notes, close to the time it was given.
if the practitioner is asked a question that is outside his or her range of expertise or knowledge then he or she should admit this, rather than fnake statements which could be challenged by expert evidence and perhaps bringinto question dieveracityinother evidence that they give.
Medical practitioners should try to use simple and concise simple English in place of acronyms and obtuse medical terms e.g., 'a unilateral circumocular haematoma', when he or she could have said, a black eye'.Go to an explanation of the new rights for family Carers; at Inquests and following tragedies
In England, [for 2004 ...clusters of local areas with very high rates of suicide were still found in Cornwall, inner north London, and coastal areas of Sussex, although the number of local areas with a rate 50 per cent or more higher than the UK rate had fallen slightly from 23 to 20. The number of areas within England with a suicide rate 25-49 per cent above the overall UK rate also decreased (from 28 to 20).Following a situation thought to be suicide there will be an Inquest.
go to a summary of an External Inquiry Report into a cluster of suicides in one Trust, and it's view of the internal review service and the relationship of a public body with the Coroner
Extracted from that External Inquiry about the role of those responsible for defending the actions of a public body." Public bodies are given their duties under statute. Their first duty is to discharge the statute, defending themselves for any perceived shortcomings in performance is wholly subsidiary to that end. Health Trusts accordingly should first strive to give care to the best of their ability, and where problems arise their duty is to investigate, acknowledge and improve in order to fulfil their statutory duty to attend to other patients. Defensive conduct that minimises or evades the full examination of such incidents in whatever forum through a desire to protect the Trust is likely to be in open conflict with that primary duty of continuing care. This is the distinguishing factor between the public and private sector, which justifies the continuation of public trust. It is the foundation of public accountability."
a Cornwall Coroner asks ... a newspaper reports
The Coroners Office Information leaflet.
You telephone them if you want to know when and where a particular Inquest will be held.
This leaflet from the Coroner's Office tells you what standards of performance are to be expected in the coroner service, and what to do if something goes wrong. This relates to the coroner service in Cornwall.
The Cornwall Coroners' office is situated at 14 Barrack Lane, Truro, Cornwall, TR1 2DW. The office is open from 9.00 am to 1.00 pm and from 2.00 pm to
5.00 pm Monday to Friday with the exception of public holidays. The telephone number is 01872 261612 and the fax number is 01872 262738.The Legal position
TheCoroner Service operates within a legal framework. It is the duty of Coroners to investigate deaths which are reported to them and which appear to be due to violence, or are unnatural, or are sudden and of unknown cause, or which occur in legal custody, and to carry out certain related responsibilities.
[ Editor Micakernow: one advice from a Coroner, describing the duties - " The coroner shall have a jury if he has reason to suspect that the death occurred in circumstances, the continuance or possible recurrence of which is prejudicial to the health and safety of the public".
Conduct
Coroners and their Officers will treat the bereaved and other members of the public, courteously and sympathetically at all times, and will have regard, within the constraints of the statutory duties, to the deceased's religious faith and cultural traditions.
Duties will be discharged impartially, with a view to ascertaining the facts surrounding a death for the purpose of the Coroner's statutory responsibilities.
Confidentiality will be preserved as far as possible within a system based on public court hearings. Explanations for the procedures adopted in particular cases will be given, on request, where the Coroners are satisfied that the person has a proper interest.
Correspondence
Written enquiries to the Coroner from a properly interested person will normally receive a reply within 10 working days of receipt. If the matter cannot be resolved within that time, an acknowledgement will be issued within 5 working days with an estimate of when a substantive reply will be sent.
Contact and Enquiry Points
The Cornwall Coroners' office is situated at 14 Barrack Lane, Truro, Cornwall, TR1 2DW. The office is open from 9.00 am to 1.00 pm and from 2.00 pm to
5.00 pm Monday to Friday with the exception of public holidays. The telephone number is 01872 261612 and the fax number is 01872 262738. Out of office hours contact can be made through most Police stations within the district through the central switchboard of the Devon & Cornwall Constabulary on 08705 777444.
Court hearings may be heard at Municipal Buildings, Boscawen Street, Truro; The Willows, Cross Street, Helston or Penzance Magistrates' Court, St Johns Hall, Penzance, for West Cornwall, and Bodmin Magistrates' Court; Liskeard Magistrates' Court; Launceston Magistrates' Court and the Posthouse Centre, Bude, for East Cornwall or at other appropriate venues. The Courts have toilets, separate waiting facilities and telephones. With the exception of The Willows, Cross Street, Helston, there is satisfactory access for the disabled with access for wheelchairs. The venues are chosen having regard to the balance of convenience for those attending. Those wishing to attend Court who have disabilities are requested to notify the Coroner's office as soon as possible so that the most suitable venue can be chosen. Those wishing to attend Court who have any special requirements including, for example, translating or interpreting services are also requested to contact the Coroner's office in advance.
A map giving directions to the location of the Court is available from the person summoning your attendance or from the Coroners' office.
Coroners and their staff will identify themselves by name in their dealings with members of the public. Deputy and Assistant Deputy Coroners act when the Coroner is not available. In doing so, they exercise the full powers of the Coroner.
Inquiries not requiring an Inquest
If a death is reported which does not need to be the subject of an Inquest, a Certificate giving the cause of death will normally be sent to the Registrar of Deaths within 5 working days of the date of the Report to the Coroner. If there is likely to be any delay in sending the Certificate to the Registrars, the Coroner or the Coroner's Officer will advise the relatives and explain the reason for the delay.
Post mortems
When the Coroner decides that a post mortem is necessary, wherever possible, the immediate next of kin whose details are known will be given:
· An explanation why a post mortem is necessary and what is involved, if requested.
· Advance notice of the arrangements, so that they may be represented (by a doctor) if they wish (but post mortem examinations must normally be undertaken as soon as possible, usually within 24 hours of the discovery of the death). Notice may not always be practicable.
· A copy of the post mortem report, if requested. (A copy of the post mortem report is normally sent to all deceaseds' General Practitioners as soon as the Coroner's enquiries have been completed. It should be noted that the Coroners' Officers and administrative staff are not medically qualified and an interpretation of the report should be sought from a medical practitioner).
Before the Inquest
Interviews
If the Coroners or their Officers need to interview someone about a death, the aim will be to do so no more than once, at a time and place convenient to the person concerned. If the person wishes, they may be accompanied during the interview by a relative, friend or other person. Every effort will be made to avoid causing any additional distress to close friends or relatives of the deceased. A copy of any statement to be used at the Inquest will be provided on the day of the Inquest to the person who made it. A copy of the statement may be supplied to the Witness in advance of the hearing if requested (unless the Coroner has good reason not to release it).
Administrative arrangements
The Coroner will notify those asked to attend an Inquest:-
· The date and time of each hearing (if more than one) at least 10 working days in advance, except in cases of urgency or where shorter notice is acceptable (but note that the formal opening of the Inquest - for taking evidence of identity and the medical cause of death - will take place as soon as possible and normally within 3 working days of the report of the death, at which point the body will normally be released).
· Details of the location of the Court where the Inquest will be held and the facilities which will be available there.
· Details of the telephone number and a named contact for enquiries.
And will:
· Advise of the availability of a leaflet explaining the purpose and procedures of Inquests
· Advise those who express a wish to do so that they may attend an Inquest as an observer beforehand.
· Explain to those called as a Witness or Juror how to claim for travel and subsistence expenses and for financial loss allowances.
· Ascertain any preference for swearing evidence (eg in accordance with specified religious beliefs, or on affirmation).
Timing
The Coroner will endeavour to hold any necessary Inquest at the earliest possible date. Most Inquests will take place within 3 months of the death. However there may be factors outside the Coroner's control which can cause delay. Where the Inquest is likely to be delayed the Coroner will notify interested persons of the position, including the reasons for any continuing delay, on a regular basis, unless the Inquest has been formally adjourned to a specific date.
Release of the body
The Coroner will release the body of the deceased for the funeral at the earliest opportunity normally within 3 working days after the report of the death is received. Where there are uncertainties as to the cause of death, or where the death is suspicious, it may be necessary to retain the body longer for further investigation. The Coroner (usually through the Coroners' Officers) will ensure that relatives are advised of potential delays and the reasons for them.
Disclosure of information
The Coroner will promptly on request and at his/her discretion, provide to properly interested persons, in advance of the Inquest, copies of the post mortem report on payment of the prescribed fee.
Jurors
For Jurors, the Coroner will:
· Send a leaflet explaining the duties of a Juror at an Inquest, and providing other relevant information 10 days beforehand.
· Provide an indication in advance of how long the Jury service will last.
After the Inquest
On the conclusion of the Inquest, the next of kin will be provided with a written explanation about how, where and when a copy of the Death Certificate may be obtained.
If, in the interests of preventing further fatalities the Coroner decides to report the matter to a relevant person or authority, he/she will do so within 10 working days of the Inquest outcome. Copies of the Coroner's letters will also be sent to all properly interested persons.
The Coroner will supply within 7 days of request by a properly interested person, on application, a copy of the Inquest verdict and will supply a copy of the Notes of Evidence and of documents produced in evidence within 42 days of receipt of the
prescribed fee (which will vary according to the number and size of the documents to be copied). An estimate of the fee will be provided in advance.
The Coroner will normally pay Witness and Jury expenses at the conclusion of the Inquest. Exceptionally it may be necessary for large or unusual payments to be submitted to Cornwall County Council who will arrange direct payment from the County Treasurer.
Application for permission to remove a body abroad
The Coroner will make every effort to complete his/her enquiries and decide such applications within 5 days of receipt of notice including weekends and Bank Holidays.
Treasure Inquests
Coroners have responsibility for enquiries into treasure finds. Information leaflets about treasure are available from the Coroners' office.
Feedback and Complaints
Coroners will not normally enter into correspondence about the cases they have completed, but comment and suggestions on improving the Coroner service are always welcome. Please contact the Coroners' office at the address given earlier. The aim of the Coroner service is to provide a service of excellence so that you should have no cause for complaint, but if you do, the complaint will be dealt with speedily and courteously.
· Complaints about a Coroner's decision or the outcome of an Inquest can only be dealt with through the High Court. The Coroners' office will be able to explain the procedure on request, but cannot give legal advice.
· All complaints about the administration of the Cornwall Coroners' service, or the conduct of individual Coroners or their staff should be raised in the first instance with the Coroner concerned by writing to him/her or telephoning him/her at the address given earlier. The Coroner will reply to such complaints in accordance with the time scales set out above.
· If the Coroner fails to deal with the complaint satisfactorily, the complainant may refer it to the Home Office (Coroners Section, Room 972, 50 Queen Anne's Gate, London, SW1H 9AT. Telephone 0207 273 2029/4000). The Home Office has no disciplinary powers or power to award compensation but may, in appropriate cases, refer the complaint to the Lord Chancellor who is responsible for the discipline of Coroners.
Performance
The Coroners' and Council's performance will be monitored regularly against the standards detailed in this document.
Further Information
Further copies of this charter may be obtained from the Coroners' office. General information is contained in the Home Office leaflet, "The Work of the Coroner", which is also available from the Coroners' office. The Home Office booklet "Your Jury Service in the Coroner's Court" can be obtained from the Coroners' office.
This charter was first issued on 31st March 2001 and will be reviewed on 31st March 2004.
Leaflets - the Benefits Agency produces a leaflet (D49) called 'What to do after a death in England and Wales
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250mishaps and tragedies Inquests tragedies and families
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